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FP-056
(Rev. 1.26.2015)
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527 CMR 1.00
Section 1.12.8.2.1
Form 1
Application lbr Pcrmit, Permit, and Certificatc of Completion for the
Installation or Alteration of FueI Oil Buming Equipment and the Storage of Fucl Oil
Permit#'s: FD l0?4t1 Elec.
(Date)
FeePaid: ,5,f4fp(City or Town)
FDID#
Owner/Occupant Name i.os Fr.' Fr
lnstattation Address: .16 1e^h Lro.\A L""".c-
/ Heating Unit Domestic Water Heater
Location: Ma.,*"^t-
Ter.#: lo( -t^*<.L).Lt{
Power Vent
Serviced Floor or Unit #:
Other
Burner:>4 New
t1, , \r.,.Fl-
Existing
-=.:;il
Mfg:
Type
druetoit Kerosene
Storage Tank: New Existing Location
Type Capacity: _ gallons No. of Tanks:
Waste Oil
Nozzle size: 7e fD
Removal
Special requirements (or additional safety devices)
OSV valve Oil Line Protected
Co. Name
Address:
Completion Date { n )r',It
Combustion Test: Gross Stack Temp
CO, Test:
City lu)S kr
ret# ))Lt -A7i-)0J-5
zip:04 63i
M.G.L. Chapter 148 and 527 CMR 1.00
now in proper operating condition and
(or alteration) was made.
Signature (no Stamp)
J
Net Stack Temp
Breech Draft
Smoke: _Overfire Draft Efficiency Rating %
ersigned certify that the installation of fuel burning equipment has been made in accordance with
in effecl. Furthermore, this installation has been tested in accordance with such requirements, is
instructions as to its use and maintenance have been lurnished to the person or whom the instal
-1''-J 65o x \J.\0Gt
Ced of C#
I, the lnd
currently
complete
lnstaller:
Address:
Once signed by the fire d
City:B rL.^)fkr
, this is PERI\y'lT for the storage of fuel oil and use ol the oil burning equipment
Date:4Approved by
Keep original as application. lssue duplicate as permit. This form may be photocopied
''{ nrngr,$. 5-Lo'11
Model # or Size:AFL